Further Long-term Studies Are Required

The authors described the results of a controlled randomized study of combined tonsillectomy-uvulopalatopharyngoplasty (TE-EPPP) in patients with obstructive sleep apnea (OSA) and tonsillar hypertrophy with velopharyngeal obstruction (1). The study results imply that TE-UPPP results in selected patients in a reduction of the apnea-hypopnea index (AHI) and daytime sleepiness. However, a closer look reveals several limitations.

Relevant tonsillar hypertrophy can undoubtedly constitute the reason for defining the indication for tonsillectomy in children and adults with OSA. Furthermore, however, it should be borne in mind that the risk of oropharyngeal obstruction is also determined by other static (anatomy) and dynamic (pharyngeal muscle tone, position of the body) factors. It is likely to be due to the complexity of these associations that thus far, no surgical treatment approach to OSA has been found to be of similar effectiveness for reducing the AHI as CPAP therapy. The question will have to remain unanswered as to which degree of tonsillar hypertrophy is relevant, and for which patients it can be reliably predicted that they would benefit from surgery with regard to AHI and daytime symptoms. Additionally, the present study did not show whether additional UPPP offers additional benefits over solely tonsillectomy or not.

In the study the mean follow-up period was 4.4 months. As the authors rightly say, no conclusions about the long term effectiveness of the surgical treatment can be drawn from this. Several factors in the study give rise to the suspicion that at least one third of patients whose surgery was initially successful will over time again exceed the threshold to OAS requiring treatment (2, 3). For this reason, further long term studies are required that take account of the different surgical approaches and that focus on the stratification of appropriate groups of patients.